Wasted: The millions spent trying to boost Scottish healthcare

A LUCRATIVE new contract for Scottish GPs that gave them a 38 per cent pay rise over three years has failed to reduce health inequalities or improve access for patients.

A damning report today reveals there has been only limited progress for patients in several key areas – despite the contract costing £160 million more than anticipated. Campaigners said it was "shocking" the deal with family doctors had yet to tackle some of the biggest problems facing the NHS.

Matthew Sinclair, a policy analyst at the TaxPayers' Alliance, said: "With resources strained paying for new drugs and higher pay across the health service, and hard-pressed families already taxed to the limit, taxpayers can't afford for their politicians to be giving away their money like this.

"Across the NHS, we've seen new contracts offer little improvement in standards despite big increases in spending. This is another failure to deliver taxpayers value for money."

Key findings from today's report by Audit Scotland include the fact the contract has failed to divert more resources to deprived and rural areas.

There was also little evidence patients can see a GP more easily now, with most health boards not believing the contract had helped improve access.

And auditors found a lack of basic information on general practice in Scotland, such as staff numbers and workload, making it difficult for the NHS to plan effectively.

But the report did find some benefits for patients from the new contract, including better monitoring of conditions such as diabetes, as well as improving the working lives of GPs.

After lengthy contract negotiations between the UK governments and GP leaders, the new General Medical Services contract (nGMS) was hastily introduced across Scotland in April 2004. Between 2004-5 and 2006-7, NHS boards were given £1.87 billion to pay for general medical services under the contract. But they ended up spending £2.03 billion – some £160 million more than allocated over three years.

Audit Scotland said there were signs some aspects of patient care had improved, such as a greater focus on chronic conditions such as asthma and heart disease.

The report also said GP practices were receiving larger incomes and doctors had a better work-life balance, having been given the option to stop out-of-hours working under the new contract.

But the report highlighted several areas where more limited progress had been made, or no progress at all, despite the huge sums being invested.

It said that "no progress" had been made in directing greater resources to areas most in need, such as deprived and rural parts of the country, because of guarantees made to practices that none would lose money under the new contract.

Audit Scotland found limited evidence nGMS had made it easier for patients to see a GP.

One issue highlighted was the fact GPs only have to demonstrate they have systems in place to be able to see patients within a 48-hour target – they do not actually have to show they achieve the target.

Barbara Hurst, director of the team that produced the Audit Scotland report, said they had flagged up this concern previously and action was needed to address the issue.

"It is fine to have a system to help meet the target, but you need to demonstrate that people are getting that access. That is important to patients," she said.

Few health boards – just four out of 14 – told Audit Scotland they believed patient access had improved as a result of the deal with family doctors.

Margaret Watt, chairman of the Patients Association, criticised the lack of foresight in predicting how much the contract would cost.

"It is shocking that so much more was spent on this contract than they expected," she said. "If all this extra money has been put in and we are not making any in-roads into the problems faced by patients, what are we doing about it? This is taxpayers' money we are talking about."

The majority of the extra costs experienced as a result of the contract came from the introduction of the incentive scheme, known as the Quality and Outcomes Framework (QOF).

Under this, GPs earn points for meeting certain indicators, such as maintaining a register of people with serious conditions such as asthma and heart disease and carrying out blood pressure checks.

But QOF was not piloted or tested ahead of being introduced. "This was a serious omission, as experience of previous incentive schemes for GPs indicated that achievement levels would be high," Audit Scotland said.

Because of the lack of planning and underestimation of the cost, QOF led to a £43.6 million shortfall in 2004-5 alone. This cost had to be met by health boards from other parts of their budget.

Boards also faced the extra cost of providing out-of-hours services where GPs opted out – up to £68 million in 2006-7.

Overall, the cost of providing general medical services rose by 40 per cent, from £503.9 million in 2003-4, before the new contract, to £706.1 million in 2006-7. This compares with a 27.6 per cent rise in the NHS in Scotland overall.

Other concerns raised by the report include the fact that QOF could have disadvantaged rural practices, whose small patient lists mean they may not have people eligible to monitor for particular illnesses.

The report also pointed out there was no evidence to show the new contract had increased the number of GPs in areas with a lower proportion of doctors per head of the population.

Audit Scotland said the Scottish Government needed to do more to monitor the impact of the contract, as well as consider its failings when negotiating new contracts. Ms Hurst said: "

There are lessons to be learned when negotiating future contracts in the health service.

"In this case, there was not good enough information about what was going on in GP practices prior to the contract.

"So, the health department in Scotland estimated that GPs would achieve around 80 per cent of the points available in the QOF. That was a massive underestimate. The actual percentage is in the high 90s and, of course, that is going to cost more."

Dr Dean Marshall, chairman of the British Medical Association's Scottish GPs committee, said the new contract had been needed to tackle recruitment problems, and the fact many GPs had been threatening to leave due to their heavy workload under the previous deal. He also said patients were seeing the benefits of the contract in improved services.

Nicola Sturgeon, the health secretary, welcomed the benefits of the contract highlighted by the study. "However, the report highlights the fact that there was a substantial underestimate of the resources required to implement the incentive payment system for the quality of care," she said. "The report also highlights concerns over the provision of basic management information about general practice in Scotland and the impact this can have on planning.

"We must now build on the improvements for patients the report identifies and work to address the lack of information on GP practices the report reveals."

Did a major cash injection make any difference?

EXPECTED BENEFIT: Expansion of general medical services

PROGRESS: Some progress

The programme of "enhanced services" has allowed NHS boards to expand the services provided by primary care – for example, sexual health or alcohol addiction clinics. Audit Scotland said there was scope for this to continue to develop.

EXPECTED BENEFIT: Better control over GP workloads and more flexibility in job opportunities for doctors

PROGRESS: Some progress

Allowing GPs to opt out of out-of-hours work has improved the work-life balance for doctors. An increased use of salaried GPs by NHS boards – those not covered by the new contract – means GP partners are working an average of three hours less a week.

EXPECTED BENEFIT: Reduced pressure on acute NHS services

PROGRESS: Limited progress

In some cases a small number of services have moved from hospitals into primary care, such as reviews of patients with type 2 diabetes. But Audit Scotland said there was no evidence to show that the resources were following the patients.

EXPECTED BENEFIT: Greater flexibility in commissioning general medical services

PROGRESS: Some progress

Audit Scotland said some NHS boards were introducing services managed by themselves, but the majority of services were still provided through GP practices. In Scotland, NHS boards have not commissioned services from the private sector, as has happened in England.

EXPECTED BENEFIT: Allocation of resources based upon patient need – eg, in deprived and remote areas – and reducing inequalities across Scotland

PROGRESS: No progress

Funding for services is not distributed in relation to where the cost of providing medical services is higher, such as in deprived and rural areas. The incentives scheme also means that remote practices may find it harder to achieve as well, due to having fewer patients on their lists.

EXPECTED BENEFIT: Improve convenience, choice and access for patients

PROGRESS: Limited progress

The number of services provided through GP practices has increased. But access to GPs is monitored only in relation to whether a practice has systems in place to help achieve a 48-hour access target – they do not actually have to show the target has been met.

EXPECTED BENEFIT: A quality framework introduced to manage patients with chronic disease

PROGRESS: Some progress

The Quality and Outcomes Framework (QOF) has improved the recording and monitoring of patients with some diseases. It is estimated that 23 per cent of consultations in GP practices relate to QOF.

EXPECTED BENEFIT: Reforming emergency (out-of-hours) care

PROGRESS: Limited progress

Audit Scotland said NHS boards had concentrated on maintaining services rather than reforming out-of-hours and unscheduled care services.

EXPECTED BENEFIT: Improvement in recruitment and retention of staff

PROGRESS: Some progress

The number of GPs in Scotland has increased from 4,456 in 2004 to 4,721 in 2007. A lack of data means it is not possible to say how many are part-time or full-time GPs, but the figures do suggest an increase in GP numbers overall. Audit Scotland said there was a lack of comprehensive data on GP and practice staff numbers, roles and workload, making it difficult to assess improvements in recruitment and retention. The average net income of GPs who moved on to the new contract increased by 38 per cent between 2003-4 and 2005-6.

EXPECTED BENEFIT: More flexibility in the structure and skill mix of general practice – eg, more use of nurses

PROGRESS: Some progress

There is some evidence that practice nurses are becoming much more involved in the regular treatment of patients with certain conditions, such as asthma and diabetes.

Key figures who helped to introduce GP contract

ALAN MILBURN, former health secretary in Westminster, was a key player in bringing about the new GP contract after lengthy negotiations which lasted from 2001 until June 2003. GPs were worried some would lose out under the new deal, but the government stepped in to guarantee a minimum income.

HAMISH MELDRUM, of the British Medical Association's GP contract negotiating team, helped to bargain for the best deal for doctors under the new contract. Dr Simon Fradd, a fellow GP negotiator, later said doctors were stunned by what they were able to get, including an opt-out of out-of-hours care for just a 6 per cent cut in pay.

Scotland was always represented during the UK-wide GP contract negotiations. MALCOLM CHISHOLM, former Labour health minister, introduced the legislation to the Scottish Parliament. He told MSPs at the time: "There is much in the bill for GPs, but there is even more for patients and for the whole of the NHS."